Medicine: Rheum Flashcards
What are the key parts to a rheum hx?
PC - joint pain, stiffness, swelling
SHx - functionality, job, driver, smoking, drug compliance
SRV - skin, eyes, renal, constitutional, fatigue
What does the timing of the stiffness indicate?
Early morning, within ~half an hr, inflammatory
Worsens throughout the day infers more degenerative
What is the DAS28?
Disease Activity Score - 28 Joints
Number swollen and tender, inflam marker, global assessment
How does the DAS28 score translate to disease activity?
> 5.1 Active
<3.2 Low
<2.6 Remission
Which is arguably the most important aspect of rheum exams?
Looking
Talk through the hand exam
LOOK
Elbows, hands, skin, nails, palms, finger pulps
FEEL
Pulses, muscle bulk, snuffbox, tendon thickening, sensation, temp, squeeze MCPs then individually each MCP PIP DIP and wrists, sensation
MOVE
Active prayer and reverse, passive wrist flexion/extension, extend fingers, splay, push hands down, thumb, fists
FUNCTION
Power grip, pincer grip, pick up small object/do up button/hold pen, Tinel’s, Phalen’s, Froment’s, Finkelstein’s
What are you looking for in the elbows?
Psoriatic plaques, rheumatoid nodules, olecranon bursa, gout tophi
Where else should you look if you’re suspicious of gout?
The pinna of the ear
What are your looking for in the hands?
Hands: swelling, loss of alignment, muscle wasting, scars, symmetry
Skin/nails: pitting, ridging, nail fold vasculitis
Palms/finger pulps: palmar erythema and scars from carpal tunnel release
Boutonniere deformity @ PIP and DIP
Flexion @ PIP
Extension @ DIP
Swan neck deformity @ PIP and DIP
Extension @ PIP
Flexion @ DIP
What do nail signs suggest?
Clubbing - cardio, resp, gastro
Pitting - psoriasis
Koilinychia - iron def
Leukonychia - liver disease
Splinters - vasculitis
How do you test sensation in the hands?
Median - over thenar eminence
Ulnar - over hypothenar eminence
Radial - thumb and index webspace
Plus can do C678 dermatomes
Describe Phalen’s test
If you suspect carpal tunnel, perform reverse prayer for 60s or squeeze wrist and force into flexion for 30s, pos if any tingling/numbness
SEs of colchicine
Nausea, vomiting, diarrhoea
Which three qs do you always ask at the start of the GALS screen?
Pain and stiffness, dressing, stairs
- Do you have any pain or stiffness in your muscles, joints or back?
- Can you dress yourself completely w/o any difficulty?
- Can you walk up and down the stairs w/o any difficulty?
GALS: What are you looking for in the gait?
Smoothness, symmetry, ability to turn quickly
NB: heal to toe and tip toe walking is more neuro looking for cerebellum problems
GALS: What are you looking for during inspection?
-From Behind-
Trapezius and gluteal muscle bulk size and symmetry
Spinal alignment
Level iliac crests
Popliteal obv swelling
Hindfoot abnormalities
GALS: What are you looking for in the spine?
-From Side-
Cervical lordosis
Thoracic kyphosis
Lumbar lordosis
Schober’s test
Knee flexion/hyperextension
What does Schober’s test assess?
Lumbar flexion by placing two fingers on adjacent vertebrae and asking the pt to touch their toes and come back up again
GALS: What are you looking for in the arms?
-From Front-
Muscle bulk and symmetry
Elbow extension in anatomical position
Cervical spine lateral flexion each side
Open jaw wide and move side to side
Elbow flexion w hands behind head
Crude hand exam inc fists, thumb to each finger, power grip and squeeze across MCPs
What is TMJ pain often a/w?
RA and inflam joint disease
What else does putting hands behind head w elbow back test?
Humeral movement and functionality
GALS: What are you looking for in the legs?
-Lying Down-
Passive knee flexion, hip flexion, hip internal rotation
Patellar tap looking for a large effusion
Sweep/bulge test looking for smaller effusions
Crude foot exam inc callus formation and squeeze across MTPs
Which rotation at the hip do you perform as part of the GALS screen?
Internal
How do you record an unremarkable GALS in the notes?
GALS: NAD
What does REMS stand for?
Regional Examination of the Musculoskeletal System
Hx for Ank Spond
Fatigue, lower back stiffness > pain, early morning and after sitting then relieved by activity
Plus quick SRV
What should you do if you lose your thought in a hx?
Summarise
Ix for Ank Spond
Bloods inc HLA-B27, xray, MRI
What would you find on MRI of ank spond?
Sacroiliitis
Mx for Ank Spond
Early intervention w physio and NSAIDs then consider steroids and biologicals
What is the ACR and EULAR 2010 RA diagnostic cut off?
6 points to dx RA & <6 labelled as undifferentiated inflammatory arthritis
Outline the rheumatoid arthritis ACR and EULAR 2010 classification criteria
Tbc
Felty’s Triad
RA, Splenomegaly, Neutropenia
Hand Hx
Hand dominance, weakness, tingling, pregnant, rheumatoid, prev surgery
RFs for Gout
Age Male Injury CVD HTN CKD Diabetes Obesity Thiazide Lead FHx Diet Alcohol
Mx of Gout vs Pseudogout
Bloods: FBC, U+Es, Uric Acid
Acute Tx: NSAIDs, Colchicine, Steroids
Chronic Tx: lose wt, inc water dec alcoholic and fizzy drinks, low purine diet + allopurinol w initial NSAID cover if gout>pseudo
How can SLE be diagnosed?
> =4
Serositis
Oral Ulcer
Arthritis
Photosensitivity
Blood Disorder Renal Disorder Anti Nuclear Abs Immuno Disorder Neuro Disorder
Malar Rash
Discoid Rash
What is Hatchet sign?
The limited erosion of the lateral aspect of the humeral head found in ank spond
What do the lumbricals of the hands do?
Flex at MCP + Extend at IPJ
Which inflammatory conditions are more common in males>females? (2)
PSC + Ank Spond
What do OA hands look like?
Heberden’s @ DIP
Bouchard’s @ PIP
Base of Thumb Squaring
Psoriatic Arthritis
Psoriasis
Nail Changes: onycholysis, pitting, subungual hyperkeratosis, discolouration
Small joint arthritis involving both the PIP and DIP joints
Dactylitis
Which antibody is most specific for RA?
Anti-CCP
Ix for RA
O/e: tender, stiff, swollen, number and type of joint involved, DIP sparing
Bloods: acute phase markers, anti-CCP, rheumatoid factor
Imaging: early disease may show synovitis on US/MRI but x-rays monitor joint damage over time - loss of joint space, bony erosions, periarticular osteopenia, joint deformities
Mx of RA
- Analgesics
- NSAIDS
- Steroids
- DMARDs - conventional (methotrexate), biological (anti-TNF), targeted (JAK inhibitors)
Conventional:
Methotrexate
Sulphasalazine
Hydroxychloroquine
Biological: Anti-TNF IL-6 Receptor - toclizumab, sarilumab Anti-CD20 (target B cells) - rituximab CTLA4-Ig (targets T cell activation) - abatacept
Targeted:
JAK Inhibitors
Anti-TNF
Etanercept Adalimumab Certolizumab Golimumab Infliximab
JAK Inhibitors
Tofacitinib
Baricitinib
Upadacitinib
Filgotinib
What is characteristic of the spondyloarthritides?
HLA B27 Arthritis Sacroiliitis Iritis Dactylitis Enthesitis
What is the ASAS classification of axial spondyloarthritis?
Aged <45 w at least 3mnths of back pain
Must have sacroiliitis on imaging plus one other feature or HLA B27 plus two other features
What drug won’t work for axial spondyloarthritis?
Conventional DMARDs
Mx of Ank Spond
- Analgesics
- NSAIDS
- DMARDs - biological (anti-TNF and IL-17 blocker) + targeted (JAK inhibitors)
What is the ASAS classification of peripheral spondyloarthritis?
Aged <45 w peripheral features only
Must have arthritis/enthesitis/dactylitis plus one/two other features
Psoriatic Arthritis X-ray
Loss of joint space
Erosions
Bony proliferation
Osteolysis
Spurs
Mx of Psoriatic Arthritis
- Analgesics
- NSAIDS
- DMARDs - conventional (methotrexate), biological (anti-TNFα or anti-IL17), targeted (JAK inhibitor or apremilast)
Which organisms cause reactive arthritis?
GU: chlamydia
GI: shigella, salmonella, yersinia, campylobacter, e coli
SLE
Mild: rash, arthritis, lymphadenopathy
Mod: pleurisy, pericarditis, cytopenia
Sev: renal and CNS involvement
What are the SLICC criteria for diagnosing SLE?
Must have biopsy proven lupus nephritis w positive ANA or dsDNA
OR
Must have four criteria including at least one clinical and one immunological
Mx of SLE
Minimise the use of prednisolone and add steroid sparing agents: hydroxychloroquine for skin and joint involvement, azathioprine, mycophenolate, rituximab, tacrolimus, cyclophosphamide for sev disease
Ix of CTD
Screen with ANA then dsDNA, ENA, cytoplasmic to confirm dx
How do you monitor treatment efficacy in SLE?
ESR
dsDNA
C3/C4
Primary Sjogren’s Syndrome
It involves inflam destruction of exocrine glands particularly the lacrimal and salivary
What should you counsel a young female with anti-Ro or anti-La abs about?
If she does get pregnant they can cross the placenta and cause fetal heart block
Where does the skin involvement in CREST not progress beyond?
Forearms/Calves
Comps of LCSS
Pulmonary HTN
Plus: ILD, renal crisis, extensive gut disease (all more common in DCSS)
Ix for Scleroderma
Dx: ANA, anti-centromere for LCSS, anti-scl70 for DCSS
Comps: ECG/echo, CXR/CT, U+Es/urinalysis
Mx of Raynaud’s
Consrv: avoid cold environments, keep whole body warm, gloves
Medical: nifedipine, sildenafil, IV iloprost
Ix for Dermatomyositis
CK ANA Myositis Ab Panel MRI Involved Muscle Electromyogram Muscle Biopsy
Ix for GCA
Acute Inflam Markers
Temporal Artery US +/- Biopsy
FDG PET Scan
Mx of GCA
Immediate PO Prednisolone 40-60mg 4w + urgent ophthal review
If visual sx: add IV methylprednisolone 500mg
If persistent/relapsing disease: add an IL6 blocker
ANCA
cANCA: a/w abs to proteinase 3 occurring in pts w GPA
pANCA: a/w abs to myeloperoxidase occurring in pts w eGPA and microscopic polyangiitis
Ddx of Purpuric Rash
Infection: meningococcal septicaemia + haemorrhagic fevers
Inflammation: HSP
Thrombocytopenia: ITP
What could you give pts who are unable to tolerate wkly alendronate?
Annual IV Zoledronate
OR
Biannual S/C Denosumab
How many wks after an acute attack of gout should you wait before starting allopurinol?
3wks
What are the RFs for CPPD?
Inc Age
Hyperparathyroidism
Haemochromatosis
Hypophosphataemia
What is the typical pt w PMR?
Elderly pt w bilateral morning stiffness in shoulder and hip girdles + pain - weakness but pain makes raising arms, getting out of a chair and going up the stairs difficult
Ix for PMR
Raised ESR/CRP
Plus rule out ddx: RA - anti-CCP; Myositis - CK; Malignancy - FLAWS, bloods, serum electrophoresis, urinary bence jones protein, CT CAP
Mx of PMR
Start prednisolone 15mg/d PO and expect a dramatic response within 1wk then wean 1mg/mnth
What is the most specific antibody for SLE?
Anti-Smith
Anti-dsDNA
Tx of Raynaud’s Syndrome
Nifedipine Primrose Oil Sildenafil Epoprostenol Sympathectomy
What ab is a/w drug-induced SLE?
Antihistone
What should be performed annually in pts w diffuse systemic sclerosis? (2)
Echo + Spirometry
What ab is a/w mixed CTD?
Anti-U1-RNP
Which NSAID carries the lowest cardiovascular risk?
Naproxen
Ix for Myositis
Inc muscle enzymes in plasma ie ALT AST LDH CK and aldolase; EMG shows fibrillation potentials; MRI shows oedema if acute; autoabs anti-M2 and anti-Jo1 if acute and ILD; muscle biopsy confirms the dx
Tx of Myositis
Prednisolone
If resistant: immunosuppressives/cytotoxics
If skin disease: hydroxychloroquine/topical tacrolimus
Ddx of DIP Involvement
OA + Psoriatic Arthritis
What are the three best tests for monitoring activity in SLE?
Anti-dsDNA
Complement
ESR
Which DMARD causes azoospermia?
Sulfasalazine
Which DMARD causes retinopathy?
Hydroxychloroquine
Why may a pt w polymyalgia rheumatica appear weak?
Pain inhibition > true weakness of limb girdles
What are the Gell and Coombs classification of hypersensitivity?
I - Anaphylactic IgE
II - Cell Bound IgG/M
III - Immune Complex
IV - Delayed T Cell
What is the defect in Marfan’s syndrome?
FBN1 gene, chr15, fibrillin-1
What might dilation of the aortic sinuses lead to?
Aortic Aneurysm
What cardiac features can be found in Marfans pts?
Aortic aneurysm, dissection, regurg + mitral valve prolpase therefore require annual echo +/- meds
Inf MI + complete heart block tx
Consrv is asx and haem stable or w atropine if also chest pain, syncope, HF or shock
Ant MI + complete heart block tx
Pacing
Ix to rule out and confirm dx of SLE
Rule out: ANA has the highest sensitivity
Confirm dx: anti-dsDNA has the highest specificity
What should be screened for following dx of dermatomyositis?
Underlying malignancy typically ovarian, breast, lung
What are the skin features of dermatomyositis?
Photosensitive, heliotrope rash in periorbital region, Gottrons papules over dorsum of hands
cANCA vs pANCA
cANCA: targets PR3 + pos for GPA
pANCA: targets MPO + pos for eGPA, microscopic polyangiitis, UC/PSC
Mx of ANCA associated vasculitis
MDT: rheum, resp, renal
Ix + Mx for GCA
Ix: inflam markers + temporal artery biopsy
Tx: high dose pred + urgent same day ophthal review
Typical demographic of ank spond pt
Young Male
Ix + Mx for Ank Spond
Ix: inflam markers and HLA-B27, spirometry, imaging
Mx: encourage reg exercise, physio, NSAIDs, DMARDs if peripheral joint involvement, anti-TNF if persistently high disease activity despite conventional tx
What does the x-ray of sacroiliac joints show in ank spond pts?
May be normal early in disease
Sacroiliitis, sclerosis, subchondral erosions
Plus squaring of lumbar vertebrae, syndesmophytes, bamboo spine (late and uncommon)
What does MRI show in ank spond pts?
Done if neg x-ray but still high suspicion which will show signs of early inflam eg BM oedema
What is the dagger sign of a bamboo spine?
Single central radiodense line on x-ray related to ossification of supraspinous and interspinous ligaments
What causes syndesmophytes?
Ossification of outer fibres of annulus fibrosus
How long should either sex wait following methotrexate tx before conceiving?
6mnths
How often is methotrexate taken?
Wkly
What should be co-prescribed alongside methotrexate and when should it be take?
Once wkly folic acid 5mg taken >24hrs after each methotrexate dose
Which pts <60yrs get pseudogout?
Underlying risk factor: haemochromatosis, Wilson’s disease, acromegaly, hyperparathyroidism, low Mg, low phosphate
What is antisynthetase syndrome?
A subtype of dermatomyositis: myositis + ILD +/- hand sx
Which abs are pos in antisynthetase syndrome?
Anti-Jo1
What are the bone profile blood tests results in pts w osteogenesis imperfecta?
Normal: Ca, PO4, PTH, ALP
What does hyperCa in the absence of elevated PTH suggest?
1° Malignancy or Sarcoidosis
What hx is suggestive of acute reactive arthritis?
Can’t see, pee or bend the knee
Def of reactive arthritis + most commonly associated organisms
Arthritis following an infection where the organism cannot be recovered from the joint
Post-Dysenteric: shigella, salmonella, yersinia, campylobacter - M=F
Post-STI: chlamydia trachomatis - M>F
How do renal comps of systemic sclerosis px + tx?
HTN + AKI +/- MAHA -> ACEi
What is labetalol commonly used for?
To acutely lower BP in haemorrhagic strokes
Preventing pathological fractures: bisphosphonates vs denosumab
Whilst alendronate is first line if eGFR <30 then denosumab is preferred
Denosumab: Dose + SEs
Dose: S/C 60mg 6mnthly or 120mg 4wkly to prevent skeletal-related events in adults w mets from solid tumours
SEs: dyspnoea + diarrhoea
What markers are used to monitor SLE flares? (2)
Dec Complement + Inc ESR
How does anti-phospholipid syndrome px?
CLOTS: clots, livedo reticularis, obstetric comps, thrombocytopenia
What is the mx for antiphospholipid syndrome?
Based on EULAR guidelines: low dose aspirin or lifelong warfarin following a VTE
What does antiphospholipid syndrome cause a paradoxical rise of?
APTT
What are the blood results for polymyalgia rheumatica?
Raised WCC/CRP/ESR + Normal CK
Mx of Gout
Acute: any CIs? NSAIDs, colchicine, pred, continue the allopurinol throughout if already taking
Chronic: started 2wks after initial attack (1) Allopurinol (2) Febuxostat
Lifestyle Mods: lose weight, red high purine foods/alcohol, stop precipitating drugs
Which drugs classically cause drug induced lupus? (3)
Procainamide (antiarrhythmic), Hydralazine (tx high BP), Isoniazid (anti-TB)
How does drug induced lupus typically px?
Arthralgia, Myalgia, Skin/Pulmonary Involvement
Which abs are a/w drug induced lupus?
Antihistone
SLE vs DIL
SLE: young + female
DIL: elderly + male
What is the adverse effect of hydroxychloroquine?
Bulls eye retinopathy which may result in visual loss, baseline ophthal exam, annual screening
Mx of OA
Consv: wt loss, encourage exercise, local muscle strengthening, braces, insoles
Medical: para and topical NSAIDs if knee/hand, oral NSAIDs w PPI, opioids, capsaicin cream, steroid injections
Surg: if above fail refer for joint replacement
Cardiac comps of Ehler-Danlos syndrome (3)
Aortic regurg, mitral valve prolapse, aortic dissection
When should sulfasalazine be avoided? (2)
G6PD def + allergy to aspirin or sulphonamide
Do you stop the pred if clinical suspicion of GCA but temporal biopsy is neg ?
No because skip lesions mean the result may show up as neg
What does systemic vasc sx + hep B signs - pulm signs suggest?
Polyarteritis Nodosa
What are the features of poor prognosis in RA? (7)
Insidious onset, poor functional status at px, extra articular features, erosions on x-ray <2yrs, HLA DR4, RF, anti-CCP abs
Outline bone protection for pts starting steroids >65yo / prev fragility # / will be >3mnths / DEXA >-1.5
Co-prescribe alendronate, calcium, vit D replete
Outline bone protection for pts starting steroids <65yo
Offer bone density scan w T score: >0 reassure + 0 to -1.5 repeat scan in 1-3yrs
What is the initial mx of RA?
DMARD monotherapy +/- short course of bridging prednisolone
What does hyperPTH put you at an inc risk of developing? (2)
Pseudogout + Renal Stones
What is the relationship b/w calcium and eye problems?
HypoCa - Cataracts
HyperCa - Corneal Calcification
Frozen Shoulder vs Polymyalgia Rheumatica
FS: unilateral + pain then stiffness
PR: bilateral + both sx together
Limited cutaneous systemic sclerosis abs
Anti-centromere abs
Diffuse cutaneous systemic sclerosis abs
Anti-Scl-70 abs
What are the 8A’s of ank spond?
Anterior Uveitis Apical Fibrosis Aortic Regurg AV Node Block Amyloidosis Achilles Tendonitis Arthritis Peripherally And Cauda Equina Syndrome
What are the clinical findings of ank spond?
Posture: loss of lumbar lordosis + accentuated thoracic kyphosis
Examination: red lateral flexion, forward flexion, chest expansion
How is forward flexion tested?
Schober’s Test: a line is drawn 10cm above and 5cm below dimples of Venus and it should inc >5cm
What are the crystals from joint aspiration like in gout, pseudogout, RA and OA?
Gout: monosodium urate, needle shaped, neg birefringent
Pseudo: ca pyrophosphate, rhomboid shaped, pos birefringent
RA: cholesterol, rhomboid shaped, neg birefringent
OA: ca phosphate, coffin lid shaped, no birefringence
What is first line mx for ank spond?
Physio + NSAIDs
What are the adverse effects of bisphosphonates? (5)
Acute phase response, oesophageal reactions, osteonecrosis of jaw, inc risk atypical stress #, hypoCa
What are the adverse effects esp w alendronate? (2)
Oesophageal ulcers + inc risk of atypical stress # of proximal femoral shaft
How should oral bisphosphonates be taken?
Taken on empty stomach >30mins before breakfast or another oral med + then remain sat/stood in that time
What do the bloods show in antiphospholipid syndrome?
Raised APTT, Normal PT, Thrombocytopenia
What is the main immunoglobulin found in breast milk?
IgA
What does low Ca and PO4 w raised ALP make you think of?
Osteomalacia
What are the possible eye signs of Marfan’s syndrome? (3)
Upwards lens dislocation, blue sclera, myopia
Do Marfan’s pts have learning difficulties?
No
What are chemo pts at an inc risk of?
Gout
Mx of Pseudogout
Aspiration of joint to exclude septic arthritis + then NSAIDs, colchicine, steroids
What are the adverse effects of sulfasalazine? (5)
Oligospermia, SJS, may colour tears
Plus resp: pneumonitis + fibrosis
Plus haem: myelosuppression, Heinz body anaemia, megaloblastic anaemia
Is sulfasalazine safe in preg + breastfeeding?
Yes
What should be checked before starting azathioprine? (2)
If the pt is on allopurinol + a TPMT test to assess risk of toxicity
What are the adverse effects of azathioprine? (4)
N+V, pancreatitis, BM depression, inc risk of non-melanoma skin cancer
Is azathioprine safe in preg + breastfeeding?
Yes in preg but use cautiously if breastfeeding
What does arthritis w nail and skin changes suggest?
Psoriatic Arthropathy
Which hand joint is predominantly affected in psoriatic arthropathy?
DIPs
What deformity is classically a/w psoriatic arthropathy?
‘Pencil-in-cup’
Ddx for HyperCa (3)
If high PTH: 1° or 3° hyperparathyroidism
If low PTH: malignancy, XS calcium/vit D, paget’s, thyrotoxicosis, adrenal insufficiency
Plus drug SEs: thiazide diuretics, lithium, vit A
How many NSAIDs must have failed before starting anti-TNFα inhibitor for ank spond?
Two + meets criteria for active disease on two occasions 12wks apart
Why colchicine>NSAIDs in elderly pt on warfarin w gout?
Risk of life threatening GI haemorrhage
Which score is useful for assessing hypermobility?
Beighton
What is used to tx acute flares of RA?
IM Steroids
What does the presence of chondrocalcinosis on x-ray point you towards?
Pseudogout > Gout
What is the z-score adjusted for?
Age, Gender, Ethnicity
What is the classic triad of Behcet’s syndrome?
Oral ulcers, genital ulcers, ant uveitis
What is the HLA association w Behcet’s?
HLA B51
What are the four spondyloarthropathies?
PEAR: psoriatic, enteropathic, ank spond, reactive
Would you find the organism in a joint aspirate of reactive arthritis?
No only in a septic joint
How regularly is methotrexate taken?
Wkly
What should be co prescribed alongside methotrexate?
Wkly Folic Acid 5mg
What interacts w methotrexate? (2)
High dose aspirin inc risk of toxicity by red excretion + trimethoprim inc risk of marrow aplasia
What clinical feature is most specific for inflammatory back pain?
Improvement w activity and not relieved by rest
What is caused by compression of the lateral cutaneous nerve of the thigh?
Meralgia Paraesthetica
What should you screen for before starting biologics?
TB, Hep B/C, HIV
What are the most commonly implicated bacteria preceding reactive arthritis?
Chlamydia Trachomatis
Salmonella Enterica
Campylobacter Jejuni
